February 5, 1999

By Christine Lehmann

The conditions in maximum-security housing units (SHUs) are so inhumane that prisoners often become psychotic. Locked up often for months in brightly-lit cells no larger than 10 feet by 8 feet for nearly 24 hours a day, prisoners are allowed minimal contact with guards and other prisoners and have to eat alone in their cells, according to forensic psychiatrist Terry Kupers, M.D., of Oakland, Calif.

Extreme isolation and sensory deprivation create what Kupers calls SHU syndrome. The symptoms include an inability to concentrate, heightened anxiety, intermittent disorientation and confusion, a sense of unreality, and a tendency to strike out at the nearest person when the breaking point is reached, Kupers told Psychiatric News.

Kupers has served as a psychiatric expert in more than a dozen class-action lawsuits filed by prisoners protesting the deplorable conditions including inadequate mental health care.

The term SHU syndrome was coined by Harvard psychiatrist Stuart Grassian, M.D., who studied the effects on prisoners of living in a SHU at a state prison in Massachusetts, said Kupers.

Mentally ill prisoners are disproportionately sent to the SHU because they have trouble coping with prison conditions and thus act out and break the rules. Their psychiatric condition and lack of mental health treatment also makes them more vulnerable to mistreatment and rape by other prisoners, said Kupers, who served as a consultant to the Human Rights Watch team investigating super-maximum security units in state prisons in Indiana.

He estimated that as many as half of the SHU prisoners he visited in state prisons in Indiana, Pennsylvania, Michigan, and California have serious, long-term mental illnesses.

Kupers described one such case in his new book due out next month, Prison Madness: The Mental Health Crisis Behind Bars and What We Must Do About It, published by Jossey-Bass.

"Willie, a 15-year-old youth, was raped repeatedly by older men while awaiting trial in jail. He has been in prison over five years, and in spite of his youth, severe psychiatric disability (diagnosed paranoid schizophrenic), and the fact he was found guilty but mentally ill, he has received very little psychiatric attention in prison besides two brief visits to a prison psychiatric unit and a prescription for antipsychotic medication.

"Left to his own devices, he quickly ran into disciplinary trouble and landed in the SHU. He has cut himself badly on his arm and neck many times. Each time he refuses an order or hurls excrement at the guards in response to hallucinated commands, he is sentenced to more time in solitary confinement, which he says makes him even more crazy."

This case illustrates the vicious cycle the mentally ill often experience in prison. After serving time in the SHU, prisoners often decompensate and are filled with rage, noted Kupers. They may be returned to the general prison population, where they get into trouble again, or released directly to the community if they completed their sentence while in the SHU.

Prisoners are often released to the community without transition planning for housing, jobs, or treatment, said Kupers. "Because their psychiatric disorder is likely to worsen in prison, these individuals are at increased risk for homelessness, psychiatric hospitalization, and reincarceration. They may also pose a danger to society."

Kupers said 41 states have a SHU or an equivalent "supermax" unit. The SHU represents a recent trend by legislators and correctional administrators to lock up even nonviolent criminals rather than invest in rehabilitation. Punishing a person for bad behavior is the norm rather than treating a person for mental illness, writes Kupers in his book.

Moreover, between 10 percent and 20 percent of the mentally ill in federal and state correctional facilities suffer from serious mental illnesses, according to Kupers. Several factors have contributed to this phenomenon, including deinsti-tutional-ization, fewer public mental health resources, criminalization of the homeless, and "the mentally ill but guilty" verdict.

Kupers estimates that the number of individuals who suffer from major mental disorders in prisons in the United States is between 120,000 and 200,000, which is far more than in the general population and exceeds the total number of inpatients in psychiatric facilities.

"The tragic result is the warehousing of a large number of mentally ill prisoners who are confined to their cells and medicated," said Kupers.

Overcrowding and idleness due to a lack of rehabilitation programs also increase the likelihood of decompensation, he noted.

Kupers, cochair of the American Association of Community Psychiatrists Committee on the Mentally Ill Behind Bars, referred to the committee's new position statement that recommends several ways to reform the correctional system:

• Address the lack of access to community mental health and dual-diagnosis services by the mentally ill who are at risk for committing crimes.



• Create alternatives to incarceration, such as mental health, substance abuse, and dual-diagnosis treatment programs for nonviolent mentally ill offenders, especially youth.



• Improve jail and prison conditions by reducing overcrowding, providing educational and rehabilitation programs, requiring mental health assessments, and reversing the trend toward using SHUs.



• Improve the availability and quality of correctional mental health and dual-diagnosis programs.



• Establish programs to reintegrate prisoners with serious mental illnesses and dual diagnoses into the community upon release.

Information on Kuper's new book is posted at the Jossey-Bass Web site at www.josseybass.com. A copy (for a $10 fee) of the Human Rights Watch 1997 report Cold Storage: Super-Maximum Security Confinement in Indiana, can be obtained via the organization's Web site at www.hrw.org.